Update: Acquired Immunodeficiency Syndrome (AIDS) -- Worldwide

As of March 21, 1988, 136 countries or territories throughout the world had reported a total of 84,256 cases of acquired immunodeficiency syndrome (AIDS) to the Global Programme on AIDS (GPA) (formerly the Special Programme on AIDS) of the World Health Organization (WHO) (Table 1).* Thirty-seven countries or territories had reported no AIDS cases. Reports are based on either the CDC/WHO surveillance definition (1,2), the WHO clinical definition (3), or a physician's diagnosis. From 1979 through March 21, 1988, the number of AIDS cases increased markedly in all geographic regions (Figure 1). The cumulative world total increased from 11,965 in 1984 to 25,150 in 1985 (a 110% increase) and to 48,413 in 1986 (a 92% increase). Because of reporting lags, the global total of AIDS cases reported for 1987 is not yet complete; however, as of March 21, 1988, 34,913 cases had been reported for 1987 (a 72% increase). Data on the distribution of AIDS cases by region are presented below, followed by a discussion of the findings.

Americas

Forty-two countries in the Americas have reported 73% of the world total of AIDS cases. As of March 21, 1988, the United States had reported a total of 54,233 cases. The case count in Brazil was 2,325; the number had increased from 801 at the end of June 1986 to 1,695 at the end of June 1987. Canada has reported a total of 1,517 cases. The following additional countries reported over 100 cases: Haiti (912), Mexico (713), Dominican Republic (352), Trinidad and Tobago (206), Bahamas (163), Colombia (153), Argentina (120), and Venezuela (101).

Europe

Twenty-eight countries in Europe have reported 13% of the world's total AIDS cases. Between December 1986 and December 1987, the number of cases reported from Europe to the WHO Collaborating Centre on AIDS (4) in Paris, France, increased by 124%. The greatest number of cases has been reported from France (3,073), the Federal Republic of Germany (1,669), Italy (1,411), the United Kingdom (1,227), and Spain (789). The highest rates per population size are in France, Switzerland, and Denmark. Four countries with over 100 cases (Austria, France, Italy, and Spain) reported increases of more than 100% between December 1986 and December 1987. The lowest rates were reported from the Eastern European countries.

Ninety-two percent of patients reported from Europe were European; 4% were African; 1% were from the Caribbean; and 3% were from other countries (4). The relative percentage of patients who have been reported from Europe but whose country of origin is Africa has been decreasing over the past 2 years.**

The age distribution of patients in Europe (Table 2, see page 293) is similar to that in the United States except that Europe has a higher percentage of patients under 19 years of age (3% compared with 2%). Europe has a lower percentage of adult patients in the homosexual and homosexual/intravenous-drug-user transmission categories than the United States and a higher percentage in the heterosexual, blood-related, and undetermined/other categories (Table 3). In addition, Europe has a higher percentage of pediatric patients in the hemophilia/coagulation-disorder category than the United States and a lower percentage with a parent with AIDS or at increased risk for AIDS.

Intravenous (IV) drug users account for 64% of adult patients in Italy and 53% of adult patients in Spain. Both countries together reported 66% of the IV-drug-related cases in Europe. In the following six countries reporting more than 50 cases, 75% or more of the patients were homosexual males: the Netherlands (88%), the United Kingdom (87%), Denmark (86%), Sweden (81%), Norway (79%), and the Federal Republic of Germany (76%).

Africa

Thirty-eight countries in the African Region have reported 13% of the world's total AIDS cases. Fifteen African countries reported more than 50 cases each. Zimbabwe*** and Zaire have each reported 300 to 500 cases, and Uganda, Tanzania, Congo, Kenya, Burundi, Rwanda, Malawi, and Zambia have each reported more than 500 cases. Central, eastern, and southern Africa have reported the largest number of cases. Although cases were first officially reported from Africa in the second half of 1982, over 70% of all cases (7,906) were reported in 1987.

Other Areas

Oceania has reported a total of 834 AIDS cases; Asia, a total of 231 cases; and the eastern Mediterranean countries, 100 cases. The major reporting countries (greater than 20 cases) from these areas were Australia (758 cases), New Zealand (74), Japan (59), Qatar (32), and Turkey (21).

Discussion

Worldwide AIDS surveillance is coordinated by GPA at WHO in Geneva. Reports are received from collaborating centers, including CDC in the United States, the WHO Collaborating Centre in Paris, and WHO regional offices and ministries of health. Accuracy and completeness of AIDS reporting vary in different areas of the world. In 1985, a review of death certificates in the United States suggested that 89% of AIDS cases meeting the surveillance definition were reported (5). In Africa, reporting has only recently started in some countries and is, therefore, incomplete. Consequently, the proportion of AIDS cases that are reported in Africa is unknown. The WHO clinical case definition, used in areas where the prevalence of HIV is high, has a specificity of over 90% (6).

Epidemiologic studies indicate three broad yet distinct geographic patterns of transmission. Pattern I is typical of industrialized countries with large numbers of reported AIDS cases, such as North America, Western Europe, Australia, New Zealand, and parts of Latin America. In these areas, most cases occur among homosexual or bisexual males and urban IV drug users. Heterosexual transmission is responsible for only a small percentage of cases but is increasing. Transmission due to exposure to blood and blood products occurred between the late 1970s and 1985 in these countries but has now been largely controlled through the self-deferral of persons at increased risk for AIDS and by routine blood screening for human immunodeficiency virus (HIV) antibody. The ratio of male to female patients ranges from 10:1 to 15:1, and, to date, perinatal transmission is relatively uncommon. Overall population seroprevalence is estimated to be less than 1% but has been measured at up to 50% in some groups practicing high-risk behaviors, such as IV drug users and men with multiple male sex partners.

Pattern II is observed in areas of central, eastern, and southern Africa and in some Caribbean countries. In these areas, most cases occur among heterosexuals; the male to female ratio is approximately 1:1; and perinatal transmission is relatively more common than in other areas. IV drug use and homosexual transmission either do not occur or occur at a very low level. In a number of these countries, overall population seroprevalence is estimated at more than 1%, and, in a few urban areas, up to 25% of the sexually active age group is infected. Transmission through contaminated blood and blood products has been a significant problem and continues in those countries that have not yet implemented nationwide donor screening.

Pattern III is found in areas of Eastern Europe, the Middle East, Asia, and most of the Pacific. HIV appears to have been introduced into these areas in the early to mid-1980s, and only small numbers of cases have been reported. Homosexual and heterosexual transmission have only recently been documented. Generally, cases have occurred among persons who have traveled to endemic areas or who have had sexual contact with individuals from endemic areas, such as homosexual men and female prostitutes. A small number of cases due to receipt of imported blood products has been reported.

Under its charter, the World Health Assembly of WHO has authorized GPA to develop and coordinate a global strategy for AIDS prevention and control. As of March 1988, 115 member states had agreed to collaborate in supporting and developing short-term (less than 1 year) plans for AIDS control. Between February 1987 and March 1988, GPA provided over 250 consultant visits to assist countries in developing these plans.

WHO is conducting worldwide surveillance of AIDS, developing standardized methods for HIV serosurveys, and creating a Global Commission on AIDS to provide GPA with scientific and technical guidance. In addition, experts have met in Geneva to discuss a variety of HIV-related issues. Health promotion and HIV prevention strategies have also been developed.**** GPA is organizing a network of specimen banks for geographically and temporally representative retroviral isolates and sera. GPA is also collaborating with a working group of leading AIDS virologists to standardize the characterization of HIV and related human retroviruses.

Although the number of AIDS cases is expected to increase significantly over the next few years, there is growing confidence that the spread of HIV can be stopped. Stopping HIV infection, however, will require a commitment that goes beyond geographic boundaries. Education and the means to eliminate or modify risk factors and risk behaviors will be the key. The global control of AIDS will require both committed national AIDS programs and strong international coordination, cooperation, and leadership. Reported by: J Chin, MD, CF von Reyn, MD, K Esteves, G Peterson, MD, E Brenner, MD, J Mann, MD, Global Programme on AIDS, WHO. JB Brunet, MD, RA Ancelle, MD, WHO Collaborating Centre on AIDS, Institut de Medecine et d'Epidemiologie Africaines et Tropicales, Paris, France. References

1. Centers for Disease Control. Revision of the CDC surveillance case definition for acquired immunodeficiency syndrome. MMWR 1987;36(suppl 1S).

2. World Health Organization. Acquired immunodeficiency syndrome (AIDS): 1987 revision of CDC/WHO case definition for AIDS. Wkly Epidem Rec 1988;63:1-7.

3. World Health Organization. Acquired immunodeficiency syndrome (AIDS): WHO/CDC case definition for AIDS. Wkly Epidem Rec 1986;61:69-73.

4. Institut de Medicine et d'Epidemiologie Africaines et Tropicales. Aids surveillance in Europe. Paris: Institut de Medecine et d'Epidemiologie Africaines et Tropicales, 1987. (Quarterly report no. 16).

5. Hardy AM, Starcher ET II, Morgan WM, et al. Review of death certificates to assess completeness of AIDS case reporting. Public Health Rep 1987;102:386-91.

6. Colebunders R, Mann JM, Francis H, et al. Evaluation of a clinical case-definition of acquired immunodeficiency syndrome in Africa. Lancet 1987;1:492-4. *Because of varying reporting practices, AIDS case data are not available for all countries for the same time period. **Such patients accounted for 12% of cases reported for Europe in June 1985, 6% in June 1986, and 4% in December 1987. ***As of April 1988, Zimbabwe officially retracted its report of 380 cases pending a national review of the accuracy of its reporting system. ****Published materials on these topics may be obtained by writing to the Global Programme on AIDS, WHO, 1211 Geneva, 27-Switzerland.

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